Surgical Breast Oncologists: Successful Innovators and Patient Advocates

The comprehensive and well-organized article by Pilewskie and Morrow[1] reviewing clinical trials in axillary surgery provides an excellent platform for applauding surgical breast oncologists for their accomplishments as innovators as well as patient advocates. This professional praise is particularly timely in an era of introspection and fiduciary scrutiny with regard to steeply rising healthcare expenses and the need for cost containment. In the area of breast oncology, screening mammography and contralateral prophylactic mastectomy have garnered extensive attention in the medical literature as well as in the popular media.[2-4] This attention has been associated with comments regarding “overdiagnosis” and “unnecessary surgery”; the oblique implication of such comments is that physician-specialist support for breast cancer surveillance and management is influenced by anticipated profit margins. The Pilewskie and Morrow review makes it clear that for the past several decades, surgeons have actually worked quite aggressively to establish standards of care in breast cancer treatment that have been progressively less invasive, less morbid, and by virtue of diminished surgical extent, less costly as well.

The paramount motivation driving advances made by the surgical breast oncology community has clearly been the desire to minimize the adverse effects of cancer surgery while continuing to respect the cancer-controlling goals of our operative techniques. Clinical trials of regional nodal surgery have reflected these motives as far back as the 1960s, when patients were recruited to an international study comparing the extended radical mastectomy vs the radical mastectomy.[5] This randomized trial revealed survival endpoint equivalence, thereby relegating the morbid internal mammary node dissection procedure to one of essentially historic significance only. In the following decade, the landmark National Surgical Breast and Bowel Project (NSABP) B-04 trial was conducted, and because it also was a study that predated widespread utilization of effective adjuvant systemic therapy for breast cancer, it further clarified the question of optimal locoregional management for operable breast cancer. The B-04 trial compared radical mastectomy (the standard of breast cancer care in that era) vs total mastectomy with locoregional irradiation vs total mastectomy without locoregional irradiation.[6] The overall survival equivalence that was observed for these three treatment arms conclusively demonstrated that outcomes from resectable breast cancer were not dependent on the disfiguring resection of the pectoralis chest wall musculature, and therefore ushered in the era of standard breast cancer management via the modified radical mastectomy.

The NSABP B-04 trial has gone on to inform contemporary discussions regarding the survival impact of an anatomically designed axillary lymph node dissection. Because clinically node-negative patients randomized to undergo definitive axillary surgery as a component of the radical mastectomy had no survival advantage compared with the patients randomized to total mastectomy (regardless of whether chest wall radiation was delivered), one could reasonably surmise that the surgical oncology community should have eliminated the axillary lymph node dissection from routine breast cancer management several decades ago. Surgical treatment trials up to that point clearly demonstrated that improvement in breast cancer survival was going to be driven by earlier detection of disease coupled with delivery of systemic therapy to control the distant organ micrometastatic burden.

No single clinical trial is conducted in a vacuum, however, and by the late 1970s, effective systemic treatments in the form of endocrine therapy and chemotherapy also became available for breast cancer. One of the humbling findings of the NSABP B-04 trial was that clinical assessment of the axillary nodal status is quite unreliable: among participants in the B-04 trial who had no physical examination evidence of axillary disease, 40% were actually found to be pathologically node-positive based on results of the radical mastectomy. In the early years of the utilization of adjuvant systemic therapy, chemotherapy and endocrine therapy were reserved for patients with the highest risk of metastatic relapse, ie, patients who were node-positive. The axillary lymph node dissection therefore remained a necessary staging component of the management of invasive breast cancer until the mid-1990s.

As we approached the 21st century, surgical breast oncologists worked tirelessly to identify some alternative to the axillary lymph node dissection as an accurate method for identifying the growing number of women diagnosed with early-stage, node-negative breast cancer. Axillary imaging and clinicopathologic prediction models unfortunately yielded disappointing results. Happily, however, in 1994, two pioneers in surgical oncology, Drs. Armando Giuliano and David Krag, published their experiences with lymphatic mapping and sentinel lymph node biopsy for breast cancer.[7,8] This exciting technology was aggressively and rapidly embraced by the worldwide community of breast surgeons, after its associated learning curve had been prudently recognized and addressed. As nicely described in the review by Pilewskie and Morrow, surgeons then proceeded to not only confirm the value of this technology for managing node-negative breast cancer, but also went on to adopt it as a minimally-invasive strategy for managing selected node-positive patients undergoing breast-conserving surgery and whole-breast irradiation.

In looking back at the strong surgical track record associated with efforts to combine oncologic clinical research principles with creativity and the desire to minimize the morbidity of regional therapy for breast cancer, it cannot be disputed that surgeons have been effective and powerful advocates for patients. This professional attribute is further evidenced by the development of breast-conserving surgical approaches; advances in breast reconstruction techniques, including the skin-sparing mastectomy with immediate reconstruction; applications of neoadjuvant chemotherapy to improve lumpectomy eligibility; and most recently, the multidisciplinary adoption of a consensus guideline regarding lumpectomy margins that will reduce rates of re-excision lumpectomies while preserving local control of disease. (This last advance was actually spearheaded by Dr. Morrow,[9] co-author of the review article discussed here.)

The progress that has been made by the surgical breast oncology community is a well-deserved source of pride. This is not to say, however, that our work is complete. We must continue to strive for speedier implementation of improved breast cancer treatments, and we must address and eliminate disparities in access to treatment advances that are related to socioeconomic and/or geographic barriers to care. Lastly, there are still a number of areas where improvements in the surgical management of breast cancer are on the horizon, but where time and energy still need to be invested in the clinical research required to define the optimal operative approach. Consider just a few examples: despite promising early clinical trials, questions persist regarding the “best” method for integrating lymphatic mapping/sentinel lymph node biopsy and neoadjuvant chemotherapy regimens; there are also questions regarding the accurate identification of biologically low-risk breast cancers that might be controlled by lumpectomy without breast radiation, or possibly even by percutaneous ablation techniques. Our success rate thus far leaves me confident that these and many other questions will indeed be definitively addressed by my talented and innovative surgical breast oncology colleagues in the very near future.

Financial Disclosure:The author has no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

References:

1. Pilewskie ML, Morrow M. Management of the clinically node-negative axilla: What have we learned from the clinical trials? Oncology (Williston Park). 2014;28:371-8.

2. Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010;102:605-13.

3. Quanstrum KH, Hayward RA. Lessons from the mammography wars. N Engl J Med. 2010;363:1076-9.

4. Guth U, Myrick ME, Viehl CT, et al. Increasing rates of contralateral prophylactic mastectomy-a trend made in USA? Eur J Surg Oncol. 2012;38:296-301.

5. Lacour J, Le M, Caceres E, et al. Radical mastectomy versus radical mastectomy plus internal mammary dissection. Ten year results of an international cooperative trial in breast cancer. Cancer. 1983;51:1941-3.

6. Fisher B, Jeong JH, Anderson S, et al. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347:567-75.

7. Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. surg Oncol. 1993;2:335-9; discussion 340.

8. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391-8; discussion 398-401.

9. Moran MS, et al. Society of Surgical Oncology–American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 2014;21:704-16.